How do these data shape your counseling when choosing among sleeve, Roux-en-Y, and GLP-1–based therapy for patients with existing reflux or elevated Barrett's risk?

Supriya Rao, MD: For patients with obesity and reflux or Barrett's risk, the study reinforces what we see clinically—that sleeve gastrectomy can worsen reflux while Roux-en-Y gastric bypass tends to improve it. In counseling, I emphasize that GLP-1s may be a little safer metabolically without increasing esophageal complications. For patients who have GERD or known Barrett's, I'm much more likely to steer away from sleeve and discuss Roux-en-Y or medical therapy first.

 What's your go-to surveillance plan (EGD timing, symptom tracking, PPI/H₂ strategy) after sleeve vs Roux-en-Y vs GLP-1 therapy, and do you favor targeted Barrett's screening at three to five years post-sleeve?

Dr. Rao: After sleeve, we watch closely for reflux symptoms. I often start a PPI early and reassess at three to six months. If reflux persists or worsens, I'll check an EGD around the three- to five-year mark—that could be earlier if there are alarming symptoms. For Roux-en-Y, the risk of reflux is lower, but I still track symptoms annually and scope if anything concerning comes up. For patients on GLP-1s, I look more closely at motility-related symptoms, and we focus on diet rather than structural changes. Of course, I maintain the same vigilance if they have prior Barrett's or dysplasia.

Dr. Rao is with the Division of Gastroenterology, Integrated Gastroenterology Consultants at Tufts Medicine, North Chelmsford, MA.